Basic Information
| Provider Information | |||||||||
| NPI: | 1780669002 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTHENBERG | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HOSPITAL AVE | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143756560 | ||||||||
| FaxNumber: | 8143722848 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 HOSPITAL AVE STE 206 | ||||||||
| Address2: | |||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142997432 | ||||||||
| FaxNumber: | 8142997434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 04/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | MD046591L | PA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | MD046591L | PA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001396577 | 05 | PA | MEDICAID |